Pembirdie

Tag: CPR

  • No one knows if you will become a vegetable

    Anytime I admit you to the hospital, I have to ask you about code status. In other words, if your heart stops beating, do you want us to try to start it again? (The process of attempting to do so is called cardiopulmonary resuscitation, or CPR.) If you are unable to successfully breathe on your own, do you want us to put a tube down your throat so a machine can breathe for you? (This is mechanical ventilation.) If you want both, that means you are “Full Code.” If you would not want CPR but would want to be on a ventilator, then you are DNR (Do Not Resuscitate). If you don’t want either, you are DNR/DNI (Do No Resuscitate, Do Not Intubate). If you want CPR but not intubation, too bad, you can’t do that. When your heart stops beating you also stop breathing, so you have to be ok with getting both. 

    On the regular, I will ask someone this question and they will answer, “I’d like you to try to revive me, but if it looks like I’m going to be a vegetable then stop.” 

    My answer: We can’t know if you are going to be a vegetable.

    (It goes without saying: you will never be a vegetable. We are mammals. Nothing medical science can do will ever turn you into an edible plant.)

    There is the question, what do they mean by vegetable. I think they usually mean, permanently unconscious: brain dead. Well, guess what. As doctors, even with the best tests we can’t generally say that 100%. There is a surprising amount of controversy in this area. I don’t think most people realize it is so gray.

    But more importantly, we aren’t God. If you heart stops, we have no idea what is going to happen when we start chest compressions, electric shocks and IV medication pushes. We can guess what we think is going to happen, but I’m pretty bad at that. Maybe you are just going to die. Maybe you will wake up in a minute and talk to us. Maybe we are going to pound on your chest for forty minutes and then you will be unconscious and on a ventilator in the ICU and maybe you will wake up in a few days or maybe not, and maybe if you wake up you won’t be able to move the right half of your body. Saying you want to be “Full Code” means you have to be ok with all of those options, you can’t just choose the good one.

    You know what I want your answer to be? If you are a healthy person over the age of 85, I want you to be DNR/DNI. If you are an unhealthy person over the age of 65, I want you to be DNR/DNI. If you are a really unhealthy person over the age of 40, I want you to be DNR/DNI. (Exception being if you are in surgery. Most people, even if they are DNR/DNI, will transition to Full Code during surgery, because it is so successful in this situation.)

    Why? Do I hate people? Do I want to take care of fewer patients?

    Admittedly, it’s probably bias. I haven’t seen that much CPR, actually. But the CPR I’ve seen has not been pretty. It has been brutal. And it has been mostly unsuccessful. Do you want the last minutes of your life to involve someone pounding on your chest, breaking your ribs, shoving a tube down your trachea, shocking your chest?

    Doctors, advanced practitioners, nurses and other healthcare providers go into medicine because we want to help people. Oftentimes CPR feels like we’re doing the opposite.

    I, as a healthy person in my mid-thirties, want CPR. I would want my husband, my siblings and my mom to have CPR. I’m not against it. It’s just not for everyone.

    SDG

  • Something everyone needs

    Everyone should have advance directives. Advance directives specify what kind of medical care you would want in the event you are unable to express a decision. Ideally, these should be written down, along with your designation for medical power of attorney (POA) – the person who would make decisions on your behalf if you can’t make them yourself. If you don’t want your closest relative (spouse, child or parent) to make decisions for you, then a document naming medical POA is essential.

    Perhaps just as important is talking with the person who would be your medical POA so they know what you would want. Ideally, if your medical POA is making decisions on your behalf, it should feel relatively easy for them because they already know what you want – they are just relaying the message to the medical team.

    Advance directives usually have a question about code status, about what you would want if you were expected to be permanently unconscious, or have an incurable and rapidly progressive medical condition that will result in death. Usually they ask if you would want tube feeding for nutrition if you can’t eat. They might ask how you would like your pain controlled, and if you want your organs donated if possible.

    One thing to note is that as humans, we aren’t the best at predicting what we will or won’t be ok with in the future. There is a principle called hedonic adaption that says that we tend to get used to nice things pretty quickly. For instance, in medical school I had the Lasik procedure. In the days that followed (after the sand-in-the-eye feeling went away), it was amazing! No need to put on glasses or deal with contacts! Everything clear! But pretty quickly it became normal.

    Now, maybe every few months I remember that my eyes didn’t used to see 20/20 and I feel a wave of gratitude, and yes, the irritation of dealing with foggy lenses or a misplaced contact doesn’t happen any more, but I can’t say that I’m particularly happier than I was before I got Lasik. My body got upgraded, and my expectations upgraded as well.

    Fortunately, the same thing can happen when our bodies downgrade. Studies show that people are able to adapt to their misfortunes. Again, I’ve experienced some of this myself. With my current hip problems, I can’t go on a casual walk or participate in a lot of fun activities. This has definitely been frustrating and life-altering and I know I’m missing out on things, but am I sad about this all the time? Nope. I don’t think my happiness level is hugely different. If I was miraculously healed and back to my “normal” self, I could see myself being a lot happier – for a week or two, maybe a month. At that point I suspect I would have adapted to my new reality. 

    SDG

  • Side effects of CPR

    Generously, one in three people who undergo cardiopulmonary resuscitation (CPR) in the hospital will survive. (Success rates are lower outside the hospital.) Congrats, that’s what you were hoping for! CPR does have side effects, however… but you only experience the side effects if it successful aka you are still alive.

    1. Broken ribs. This is the most classic side effect. The older you are, the more likely this is going to happen, because ribs get more brittle with age. If you are a little old lady, your ribs are going to snap like toothpicks. What do broken ribs feel like? As far as I can tell, nothing good. Breathing will be painful, so the temptation is to take little tiny breaths instead of big ones and to avoid coughing at all costs. Unfortunately, doing this sets you up for pneumonia, which you are already at increased risk for being in the hospital. So we’re going to be asking you to take those big, deep, painful breaths anyway. You may need to go on opioid pain medication in order to do so, which comes with its own litany of side effects (like constipation, confusion, and dependence).
    2. Brain damage. About one third of people who survive CPR will have brain damage. This does not mean you are an unconscious “vegetable.” But maybe you are. Or maybe you just can’t live by yourself anymore because it’s too unsafe.
    3. Trachea/vocal cord damage. If CPR goes on for more than a few minutes, we are going to try to place a breathing tube. In the process, the tube may injure your throat, including the vocal cords. Swallowing may be painful for about a week. Your voice may never be the same.
    4. More time in the hospital. No one comes out of CPR healthier than when they went in. You will likely end up in the intensive care unit for close monitoring, which is going to involve more tests, blood work, and interruptions. Almost certainly your hospital stay will be prolonged. Longer stays in the hospital mean greater chances for other things to go wrong.
    5. More likely to not go home. You’ll be weaker and may need to spend time rehabilitating in a nursing home. If you are fortunate, you will rehab back to home or move into an assisted living where you have more support. If you’re less fortunate, you’ll be a permanent nursing home resident.
    6. More likely to return to the hospital. Generally, hearts don’t just stop beating out of nowhere. You probably have some serious medical conditions that are not going to go away. You may also have more health problems as side effects of CPR. (See above.) As a result, don’t be surprised if you continue to get ill enough to require repeated hospitalization. Your doctors certainly won’t be.
    7. More likely to die. A study examining CPR in older adults with medical problems like heart failure, COPD, cirrhosis and cancer found more than half of them were dead in 6 months. 

    Again, you only get these side effects if CPR is successful: the alternative is being dead. The older, sicker and more frail you become, the more likely you will experience these side effects and the more severe the side effects are likely to be. You will also be less likely to survive to experience them.

    In general, if you are under sixty, I’d say it’s worth doing. (That recommendation would change if you have metastatic cancer or other severe health problems.) Over sixty becomes more gray as people accumulate more health problems. Ultimately, the decision is up to you, but it’s important to know what your decision means.

    SDG

  • On death and dying

    I haven’t had as much experience with death as some.

    On one hand, my childhood contained plenty of animal death. Cows died sometimes. My dad shot three of our dogs when they got too old to move, and we tearfully brought another dog to be euthanized at the vet when it was diagnosed with diabetes. Countless cats disappeared, and more than a few kittens kicked the bucket, some in gruesome ways. One night when I was ten or eleven, I wanted to feel sad (kids are weird) and tried to tally up all the animals I knew that had died. I can’t recall the total but it seemed like it was over fifty.

    On the other hand, I was spared the death of someone I loved until after college.

    My dad died in a plane crash the summer I turned twenty-three – that was my first real experience.

    A fact about me I’m ashamed to share: I’ve never performed CPR in a read code event. The opportunity never came up in med school, and when someone coded in the ICU during residency and I saw everyone lining up for their turn at chest compressions in what seemed quite obviously to be a futile attempt at resuscitation, it didn’t seem like giving a few of my own chest compressions was going to help me or the patient.

    I’ve observed several codes, none of which ultimately was successful. (This demonstrates how few I’ve seen, because statistically in the hospital about 1/3 to 1/4 are at least successful at restarting the heart.)

    I didn’t pronounce someone dead until my fellowship year. An older woman in my care had been placed on comfort care with the goal of leaving the hospital on hospice. She wasn’t doing well, but had been stable for several days. Right before the end of my shift, her nurse paged and asked me to come up, because my patient had died. In a moment of gallows humor, I had a shock when I was listening for a heart beat and watching the patient’s chest – it was rising and falling. Then I realized her air bed was still on. The nurse turned it off, and she was still.

    Our daughter, Lindy, died in our arms. She just gradually stopped breathing. The nurse listened to her heart and said she had died, but when the nurse practitioner came to confirm, her heart was still beating, slowly. It kept beating for a few more hours as we held her close in the hospital bed.

    Yesterday I spent the afternoon sitting next to a great aunt who is dying. Part of the time she moaned and moved her head back and forth, most of the time she slept. I don’t think she knew I was there. Her pulse was high, probably 120 beats per minute. Still breathing steady but sometimes with a rattle. I sat with her in the hospital in July and thought she was dying then, although she’s further down that path now. I don’t know how long her earthly journey will continue. Sometimes it happens so quickly, like with my dad. Other times over a few hours, with Lindy. My great aunt is taking a harder, longer road, God only knows why.

    I hate death. People say death is just a part of life, but they’re wrong. It wasn’t supposed to be like this.

    What I do know is that the God of the universe experienced death as Jesus Christ, and he conquered it.

    Resurgam.

    SDG